Healthcare Provider Details

I. General information

NPI: 1790992097
Provider Name (Legal Business Name): ANTHONY JAMES JEDWABNY ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S WESTMONTE DR STE 1208
ALTAMONTE SPRINGS FL
32714-4200
US

IV. Provider business mailing address

178 PESHEKEE TRAIL
MEDFORD NJ
08055
US

V. Phone/Fax

Practice location:
  • Phone: 407-733-2841
  • Fax:
Mailing address:
  • Phone: 407-862-0714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: